Breastfeeding–Preventive Medicine for Pain?

Somewhere during the excitement and preparations for all the many holidays that occur in November and December, culminating with the global ringing in of the New Year, a new issue of Breastfeeding Medicine was published, the last of 2010. As always it contains a number of articles that are timely, interesting and on the forefront of lactation research. It also has the newest ABM Clinical Protocol to be added to our slowly, but ever-growing list, Clinical Protocol #23: Non-Pharmacologic Management of Procedure-Related Pain in the Breastfeeding Infant. Long title. Important concept.

It wasn’t that long ago that the medical profession did not think babies even felt pain. What a horribly painful thought. Having had personal experience with chronic excruciating pain, I cannot fathom that thought. “Minor” procedures were done with no anesthesia or analgesia—non-ritual circumcisions (we could go off on a tangent here about whether or not that even should be done, but I promise to stay on task…) being the most well-known. But so were “major” procedures.

I am definitely not a young chickadee any longer, as my teenage daughters will readily tell you, but I am not headed for the nursing home any time soon either I don’t think. True story—when I was a second year resident in Pediatrics, in charge and alone covering all of pediatrics one night–the floor (ward), emergency room full of asthmatics getting epi shots, theophylline drips and bronchodilator aerosols (I think that dates me) and the delivery room at an “out-lying” affiliated hospital to my Pediatric residency primary Children’s hospital (we are talking major metropolitan area in the United States, not out in the wilderness) a pediatric surgeon came barreling in the middle of the night after the unexpected delivery of a baby with a diaphragmatic hernia (yes Virginia, those things used to happen in the days before “routine” ultrasounds) and right there to my and the nurses horror, he performed an emergent laparotomy with no anesthesia, no analgesia on the open warmer I was slaving over to stabilize the baby, to pull the intestines out of the chest before transport…. A sight I have NEVER forgotten.

So, as the saying goes, we’ve come a long way baby. We recognize pain in even our most immature babies (I hope), and try our best to prevent or alleviate it. Anyone who has worked in a neonatal intensive care unit has seen and heard of the use of narcotics (which will relieve pain) and sedatives and anxiolytics (which we must remember don’t relieve pain, but often settle the baby down and make it easier to control the pain with narcotics, or at least we believe so). And that makes sense for major pain, like intubation and incisions and chest tubes and of course, surgery.

But what about the countless other things we do to babies, both sick and premature, and well and term that are noxious and painful—heel sticks for blood draws, Vitamin K injections, numerous immunizations, and yes, circumcisions being at the top of the list. We know from the literature that pain can have long-term detrimental consequences and that pain-reduction therapies are under-utilized in this age group. We also know there is a growing body of evidence that non-pharmacological means of pain reduction not only exist, but are effective. And guess what? The safest, most cost-effective, natural and supportive of the breastfeeding relationship is—you guessed it—Breastfeeding!

This new ABM protocol, which can be found on our website at www.bfmed.org, under the Protocols tab, is worth taking a good look at. It presents the data on pain relief we have now in 2011 on breastfeeding as an entire act; the various components seperately—the milk, the sugar, skin-to-skin; the use of sucrose and pacifiers; in term babies; preterm babies; and what we know of older babies. And it points out as always where the literature is lacking, where we need further research.

This protocol, like all others before it, is a long, thoughtful, extensive review of the literature and comments by experts in the field, which undergoes multiple reviews and re-writes before publication. It is the state of the art and the science as we know it at the time of publication. Pain is not something I would wish on anyone. If I was not already so immersed in lactation at the time of the accident that has caused me so many years of chronic pain, I would have put my efforts into the study of pain. I learned quickly that the medical profession knows little about pain and its management in adults, and the consequences of that management. The worst issues with the narcotics are not necessarily the worries about addiction, but in my view, all the other side effects associated with their use. And in pain treatment, we have ignored our youngest even more. The information included in this protocol is a great first step in educating us toward non-pharmacologic means of pain reduction in neonates. We should all be familiar with it, and use it in our practices. And we should also use it to realize how much more work there is to be done. Pain is no fun. It cannot have any positive outcomes past letting us know something is wrong and needs attention, even if it is the sting of an injection to a baby who cannot comprehend why those she trusts to protect her are doing this to her. She deserves to be comforted and to have her attention brought elsewhere, so her memory is not of the pain, but of the warmth, and comfort and love. After all, isn’t that how we are all trying to bring our babies and children into contact with our world?

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

I always nurse my kids before and during vaccinations, through countless heel sticks, and after bumps and scrapes (or anything that really upsets them). I have absolutely no doubt that breast milk, as well as the act of breastfeeding, is unmatched in its ability to soothe a child’s anxieties and lessen pain. I watch non-breastfeeding moms try unsuccessfully to comfort a severely upset baby, and I just want to put a boob in its mouth! A pacifier or formula or rocking alone sometimes just isn’t enough to calm a scared, sick, or hurting baby.

This is an interesting question. I have learned to “never say never,” but in this case, there are some important caveats. First, this is not what I would consider equal as a “minor” procedure to an immunization or a heel-stick for blood. This is an incision in a very sensitive tissue, so is very painful. The vast majority, if not all pediatricians, family practitioners and Ob’s now agree that real anesthesia is required for circumcision. So usually a regional “block” is used–the nerves to the penis are “put to sleep” with injections so there is no pain during the procedure. The other part of this is just logistical. I personally do not do circumcisions–I don’t believe they are necessary, so I have never agreed to do them. But I have seen them done. The baby is strapped down into a “mold” the shape of the baby’s body, with arms out and legs out, to expose the genitals and keep the arms out of the surgical field. That being the case, it would be hard, although not impossible, to get mom’s breast to the baby’s mouth–she would have to lean over, which would put her into the surgical field.

So that being said, when the anesthesia wears off, there is going to be pain. Tissue has been cut, and it is raw. Pharmacologic methods are appropriate. But so are the non-pharmacologic methods. So use of all the non-pharmacological pain releif methods in the protocol, breastfeeding being the one we are talking about here, become so very important. But often after circumscision babies are out of sorts and do not breastfeed well. If that is the case, then lots of skin to skin, lots of making the breast available, can only help.